1. NEUROLOGY MINI-Grandrounds PGI Batch 2010 – Group 5 26-July 2009

2. GENERAL DATA D.C. 32 year old Female Married R handed Filipino Inglesia Ni Cristo Housewife Graduate Cabalucan, Castillejos Zambales Date of Admission: 19-June 2009

3. CHIEF COMPLAINT Low Back Pain

4. History of Present Illness Jan 2009 – (+) low back pain – Lumbar area – non-radiating – 3/10 in severity – aggravated by lifting heavy objects – relieved by lying still. – No bowel/bladder incontinence

5. History of Present Illness Feb 2009 – pain radiating to both lower extremities Mar 2009 – progression of symptoms – 6/10 in severity (+) Consult – Dx: UTI / Ureterolithiasis - given unrecalled antibiotics June 17, 2009 – (+) severe low back pain – Accompanied by progressive difficulty in ambulation

6. Past Medical History (-) HPN (-) DM (-) PTB (-) CA (-) allergy (-) previous hospitalization (-) previous blood transfusion

7. Personal and Social History Occasional smoker Occasional alcoholic beverage drinker Denies illicit drug use Mixed diet

8. Family History (+) DM - grandparents (+) Cancer – mother (blood) brother (liver) (-) PTB (-) heart disease (-) allergy (-) asthma

9. Review of Systems No weight loss, night sweats No dyspnea, orthopnea, PND, no easy fatigability No palpitations, no chest pain No nausea or vomiting, no abdominal pain, no diarrhea or constipation No dysuria, urgency, frequency, hesitancy No diarrhea, no constipation No tremors No pallor, no easy fatigability

10. Physical Examination on Admission Conscious, coherent, not in cardiorespiratory distress BP: 130/90 HR: 88,reg RR: 19 T. 36.8°C Warm moist skin, no active dermatoses Pink palpebral conjunctiva, anicteric sclera, no nasoaural discharge, moist buccal mucosa, tonsils not enlarged, non hyperemic PPW, Supple neck, thyroid not enlarged, no palpable cervical lymph nodes, no carotid bruit Symmetrical chest expansion, no retractions, clear breath sounds

11. Adynamic precordium, no heaves or thrills, AB 5 th LICS MCL, S2> S1 at the base, S1 > S2 at the apex, no murmurs Breast: (-) masses, (-)discharge, (-)palpable lymph nodes, (-) skin changes Flabby abdomen, normoactive bowel sounds, soft, nontender, no masses palpated (+) paravertebral tenderness (L4-L5) Pulses full and equal, no edema, no cyanosis

12. Neurologic Examination Awake, not oriented to time and place, follows commands, recent and remote memory not intact, can write and read, cannot count Pupils 2-3 mm ERTL, (+) direct and consensual light reflex; no visual field cuts Fundoscopy: (+) ROR (-) papilledema (-) hemorrhage EOMs full and equal, no ptosis

13. V1-V3 intact, can clench teeth Able raise eyebrows, frown, close eyes tightly, able to puff cheeks No lateralization on Weber’s; AC>BC on Rinnes Uvula midline on phonation Can shrug shoulders, rotate head against resistance Tongue midline on protrusion (-) atrophy, (-) spasticity, (-) rigidity, MMT 5/5 on both upper extremities and 3-4/5 on lower extremities; Can do APST, FTNT and heel to shin with ease DTR’s ++ on all extremities (-) Babinski (-) nuchal rigidity (-) Brudzinski (-) Kernigs

14. Initial Assessment Is there a neurologic problem? Where is the lesion? What is the lesion?

15. Is there a neurologic problem? Focal Neurologic Deficits – Radicular pain, bilateral lower extremities (sciatica)

16. Where is the lesion? Levelization: Nerve Root Lateralization: Bilateral Localization: L4-L5

17. What is the lesion? Onset: Chronic Course: Progressive Type: Focal Etiology: Infectious vs Mass

18. Admitting Impression

19. Plans Diagnostic

20. Plans Therapeutic

21. DIAGNOSTIC WORK-UPS

22. AFB Stain 1 st day:negative 2 nd day:negative 3 rd day:

23. X-ray Studies Chest Xray: June 17, 2009 Fibrosis, both upper lobes Incidentally, Dextroscoliosis, Thoracic Spine Lumbosacral spine xray: June 24, 2009 Apposing vertebral end plates of L4 and L5 are indistinct Disc space between L4 and L5 are obliterated Lumbar lordosis is maintained Disc spaces are intact Thoracic spine xray: June 22, 2009 Expansile and infiltrative lesion at the paravertebral region at the L4 and L5 level with extension to the anterior aspect of S1 vertebral bodies with multi septated abscess formation and bone changes, as described, consistent with Pott’s disease

24. Magnetic Resonance Imaging MRI Thoracic Spine: June 17, 2009 Posterior compression deformity, T9 vertebral body with discs changes as described. A beginning Pott’s disease is considered. MRI Lumbar Spine: June 17, 2009 Expansile and infiltrative lesion at the paravertebral region at the L4 and L5 level with extension to the anterior aspect of S1 vertebral bodies with multi septated abscess formation and bone changes, as described, consistent with Pott’s disease

25. CBC 18-June 2009 COMPLETE BLOOD COUNTRESULTREFERENCE RANGE HGB110120-170 g/L RBC3.894.0-6.0 x10^12/L HCT0.330.37-0.54 Platelet406150-450 x10^9/L WBC5.74.5-10.0 x10^9/L Differential Count Neutrophils0.840.50-0.70 Lymphocytes0.160.20-0.40 ESR0.00-0.07 Modified Westergren59.00-20 mm after 1 hr

26. Blood Chemistry 18-June 2009 RESULTREFERENCE RANGE Urea Nitrogen16.09-23 mg/dL Fasting Blood Sugar12870.9-110 mg/dL Creatinine0.580.5-1.2 mg/dL SGOT – AST18U/L HBA1C6.014.8-6 %

27. Urinalysis 18-June 2009 ROUTINERESULT ColorYellow TransparencyClear Reaction6.5 Specific Gravity1.010 Sugar++++ ProteinNegative Microscopic Pus cells0-3/hpf RBC10-15/hpf BacteriaFew Epithelial cellsFew

28. Surgical Pathology Report July 11, 2009 Spinal Epidural mass, spine surgery: Chronic Granulomatous Inflammation with suppuration